Early donor management increases the retrieval rate of hearts for transplantation in marginal donors.

OBJECTIVES: Organ donations continue to fall, failing to meet the clinical requirements for heart transplantation. Furthermore, the pathophysiology of brain stem death including hormonal and inflammatory changes may lead to significant donor heart injury. Early donor management may potentially alleviate these changes and therefore increase the number of available hearts for transplantation. We aimed to investigate whether early management of borderline donors can increase the heart retrieval rate. METHODS: Between September 2011 and February 2013, we performed early donor management of 26 potential heart donors in the intensive care units of the respective donor hospitals. At the time of referral donors were considered as borderline based on high-dose inotrope requirements, history of hypertension and cardiopulmonary resuscitation. Our management protocol included insertion of a pulmonary artery catheter and performance of cardiac output studies, weaning noradrenaline and commencing arginine vasopressin, and administration of tri-iodothyronine, methylprednisolone and insulin. Our primary end-point was donor heart acceptance, depending collectively on the results of cardiac output studies, cardiac contractility and coronary artery patency at the time of retrieval operation. RESULTS: We retrieved 14 (56%) borderline hearts after donor management (Group A) with a 30-day survival rate of 86%. Twelve (44%) organs were declined due to poor heart function (n=8; 66.7%; P<0.001) and/or palpable coronary artery disease (n=4; 33.3%; P=0.018) (Group B). The mean age of Groups A and B was 42.77 and 47.78 years, respectively (P=0.19). Most of the female donors, i.e. 10 (83%), were declined, and only 4 (27%) were accepted (P=0.005). Majority of patients in both groups (Group A: 71.4%; n=10; and Group B: 66.7%; n=8) were on high-dose noradrenaline (>0.08 µg kg(-1) min(-2)) at the time of donor offer. Group A had a mean cardiac output of 6.29 and 3.09 l/min for Group B (P=0.01). A positive smoking history was present in 28.6% (n=4) and 33.5% (n=4) in Groups A and B, respectively (P=0.793). Cardiopulmonary resuscitation was performed on 3 (21.4%) patients in Group A and 2 (16.7%) in Group B (P=0.759). A history of hypertension was present in 7.1% (n=1) of the Group A and 33.3% (n=4) of the Group B donors. CONCLUSIONS: In our study, we were able to retrieve more than half of the potential heart donors as a result of early active donor management without impacting on the post-transplant recipient outcome. Early active donor management may assist in increasing the number of heart transplantations, thus warranting further investigation.

Segmental mediolytic arteriopathy with post-transplant lymphoproliferative disorder of the lung: case report and review of the literature.

Segmental mediolytic arteriopathy (SMA) is an extremely rare condition of uncertain etiology causing degeneration of arterial media, intramural dissection or the rupture of aneurysms. It is recognized as a rare cause of fatal intra-abdominal bleeding. We report the first case of recurrent intra-abdominal bleeding secondary to SMA in a lung transplant patient, with a further complication of lymphoproliferative disease in the transplanted lung. We discuss the pathogenesis, clinical presentation, imaging characteristics and the complexities of management in this case.

Donor heart selection: the outcome of "unacceptable" donors.

BACKGROUND: The decline in the number of suitable donor hearts has led to an increasing interest in the use of previously unacceptable donors. In the United Kingdom, if one centre declines a donor heart on medical grounds it may be offered to other centres. This multi-centre study aimed to evaluate the outcome of recipients of donor hearts considered medically unsuitable for transplantation by one centre that were used in other centres. METHODS: Between April 1998 and March 2003, ninety-three donor hearts (group A) were transplanted, after being considered medically unsuitable for transplantation by another centre. During the same period, 723 hearts (group B) were transplanted in the UK using donors not previously rejected. Data on the donors and recipients was obtained from the UK transplant database. Comparative analysis on the two groups was performed using SPSS 11.5 for Windows. RESULTS: The characteristics of recipients were similar in both groups. The main reasons for refusal of hearts are listed below. In most cases there was more than one reason for refusing the donor heart. We did not find significant differences in the post-operative mortality (up to 30 days), ICU and hospital stay and cardiac cause of death between the two groups. Kaplan-Meier survival curves showed no significant difference in the long-term survival, with Log Rank test = 0.30. CONCLUSION: This study demonstrates that some hearts declined on medical grounds by one centre can safely be transplanted and should be offered out nationally. The use of these hearts was useful to expand the scarce donor pool and there does not seem to be a justification for denying recipients this extra source of organs.

Interleukin-4 C-590T polymorphism has no role in coronary artery bypass surgery.

Interleukin-4 exerts anti-inflammatory effects through decreased macrophage production of tumor necrosis factor-alpha and interleukin-1 beta. We investigated genetic predisposition in the interleukin-4 response to coronary revascularization and studied the association between C-590T polymorphism, interleukin-4 levels, and outcome of surgery. DNA was obtained from 96 consecutive patients undergoing elective coronary revascularization. Patients were genotyped for interleukin-4 C-590T polymorphism using a sequence-specific primer polymerase chain reaction. Interleukin-4 levels were measured using an enzyme-linked immunosorbent assay in serum samples taken 3 hr postoperatively. The frequency of interleukin-4 C-590T genotypes CC, CT, and TT was 33.3%, 27.1%, and 39.6%, respectively. Patients with the TT genotype had significantly higher circulating levels of interleukin-4 (3.4 +/- 4.6 pg x mL(-1)) postoperatively compared to CC (2.5 +/- 0.1 pg x mL(-1)) and CT (2.7 +/- 0.5 pg x mL(-1)) genotypes. Interleukin-4 C-590T polymorphism is the main determinant of postoperative interleukin-4 levels. The TT genotype is the highest producer of interleukin-4. Neither the genotype nor the serum levels seem to play any role in recovery from coronary artery bypass surgery.

Extracorporeal membrane oxygenator as a bridge to successful surgical repair of bronchopleural fistula following bilateral sequential lung transplantation: a case report and review of literature.

BACKGROUND: Lung transplantation (LTx) is widely accepted as a therapeutic option for end-stage respiratory failure in cystic fibrosis. However, airway complications remain a major cause of morbidity and mortality in these patients, serious airway complications like bronchopleural fistula (BPF) are rare, and their management is very difficult. CASE PRESENTATION: A 47-year-old man with end-stage respiratory failure due to cystic fibrosis underwent bilateral sequential lung transplantation. Severe post-operative bleeding occurred due to dense intrapleural adhesions of the native lungs. He was re-explored and packed leading to satisfactory haemostasis. He developed a bronchopleural fistula on the 14th post-operative day. The fistula was successfully repaired using pericardial and intercostal vascular flaps with veno-venous extracorporeal membrane oxygenator (VV-ECMO) support. Subsequently his recovery was uneventful. CONCLUSION: The combination of pedicled intercostal and pericardial flaps provide adequate vascular tissue for sealing a large BPF following LTx. Veno-venous ECMO allows a feasible bridge to recovery.

An aberrant donor pulmonary vein during lung transplant: a surgical challenge.

Aberrant pulmonary veins are uncommon. Anastomosis of such a vein during a lung transplant operation may provide a surgical challenge. We report the first case of an aberrant pulmonary vein anastomosed to the left atrial appendage during the implantation of the left lung.

Should the pericardium be closed in patients undergoing cardiac surgery?

A best evidence topic in Cardiothoracic Surgery was written according to a structured protocol. The question addressed was in open heart surgery is there any adverse effect to closing the pericardium? Altogether 240 publications were found using the reported search of which 8 were deemed to be relevant to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that the adverse haemodynamic impact of pericardial closure is confirmed in several studies, however, no study has yet reported an adverse clinical outcome due to the closure of the pericardium.

What is the optimal medical treatment for stable cardiac surgical patients who go into atrial fibrillation after their operation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was which medical strategy is the optimal treatment for stable patients going into atrial fibrillation post cardiac surgery. Altogether 281 papers were found from medline and 83 from the Cochrane Central Register of Controlled Trials using the reported search, of which 12 presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is very little evidence to support any one strategy over another.

Low dose (renal dose) dopamine in the critically ill patient.

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether low dose (renal dose) dopamine in the critically ill patient prevents acute renal failure. Altogether 141 papers were found using the reported search, of which three presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that there is no evidence to support the use of low-dose dopamine to treat acute renal failure in critically ill patients.

Is the figure-of-eight superior to the simple wire technique for closure of the sternum?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed is whether the figure-of-eight technique is superior to the simple wire technique for closing of the sternum? Altogether 111 papers were found in Medline of which seven presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that the figure-of-eight wire technique is not superior to the simple wire technique for closure of the sternum.

Is haloperidol or a benzodiazepine the safest treatment for acute psychosis in the critically ill patient?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether haloperidol or a benzodiazepine is the safest treatment for acute psychosis in the critically ill patient. Altogether 294 papers were found using the reported search, of which nine presented the best evidence to answer the clinical question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that haloperidol should be considered the first line drug for agitated patients post cardiac surgery, however lorazepam either alone or in conjunction with haloperidol is an acceptable alternative.